Clinical Exemplar

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CLINICAL EXEMPLAR PAPER
Clinical Exemplar Paper
Hannah Ponder
College of Nursing, University of South Florida

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Noticing
My second preceptorship shift was full of chaos. My patient was an 82-year-old male
who had been in the hospital for one month. This patient had an above the knee amputation due
to a clot that was in his right femoral vein. The patient underwent surgery to have a stent placed
in the artery to help restore blood flow prior to the amputation; however, that was unsuccessful.
The patient had a history of end stage renal disease where he received peritoneal dialysis every
night, he had dementia, peripheral arterial disease, and hypotension. On the second day of having
this patient, the nurse and I noticed a severe decline in his mentality from the day before. The
patient was not as alert as he was the day before and his phrases did not make sense. This is
where we first noticed something was wrong. Followed by that, we had a harder time taking his
blood pressure and getting a reading where the systolic pressure was above 90. When trying to
give the patient medications, he vomited instantly. After vomiting up his medications, the patient
refused to take the rest. Shortly after attempting to administer the medications and performing
the morning assessment, the patient complained of a new onset of severe abdominal pain.
Interpreting
The nurse and I were aware of the client’s worsening condition. We tried non medicative
therapies for pain relief such as alternating cold and hot packs on the patient’s abdomen and
rubbing his back when he asked. The nurse and I were unable to give the patient his pain
medication because his blood pressure did not meet the parameters for the medication. Because
of this, we tried to mix his midodrine medication with other substances such as pudding, yogurt,
or gelatin to raise his blood pressure. Nothing seemed to help the patient swallow his
medications. Since the patient was unable to increase his blood pressure, we could not administer
the pain medications he had. The nurse attempted to contact the physician multiple times where
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the nurse was left on read and the provider never responded. The nurse sent out a page for the
doctor to contact her immediately. The physician returned the call, and my nurse was explaining
the client’s condition following up with a potential CT scan of the abdomen or a different pain
medication to help relieve what he is feeling. The physician stopped the nurse mid-sentence and
prescribed oral lidocaine. The patient did have mouth and esophageal ulcers, so it was thought
the oral lidocaine would help numb his upper GI tract so the patient could swallow. If the patient
were able to swallow without vomiting, he could take his blood pressure and pain medications.
Responding
Although the provider did not order a CT scan of the abdomen, the nurse and I tried the
oral lidocaine. This did seem to help numb the patient’s mouth and throat so he could attempt to
eat and take his medicine; however, it did not last long. The nurse and I agreed that a CT of the
abdomen should have been completed in case there was something else happening to this patient.
I was under the impression the patient may have had fluid that did not completely empty after
receiving peritoneal dialysis. I mentioned this to the nurse, and she stated that was a possibility.
The nurse and I tried to think of what we could have done differently. We did try to get him to
take his medications, we tried non pharmaceutical pain-relieving therapies, we tried to reposition
the patient on his side, the physician was contacted multiple times and lacked an interest in the
patient’s case. At my next shift, I was informed the patient did get a CT of the abdomen
overnight due to the unresolved pain. The findings were interstitial fluid in his abdomen.
Reflecting
Cognitive behavioral therapy can include techniques such as cognitive restructuring,
relaxation, and problem-solving skills (Cangemi and Lacy, 2019). The patient and his wife were
educated on why he could not receive the pain medication; however, his pain was also causing
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himself and his wife anxiety and worry. Perhaps the nurse and I could have attempted various
relaxation techniques to help the patient feel more at ease and take his mind off the pain he was
feeling. According to a meta-analysis from six studies, cognitive behavioral therapy had a
positive impact on improving irritable bowel syndrome (IBS) symptom severity and the
psychological distress the symptoms caused (Cangemi and Lacy, 2019). Although this patient did
not have IBS, he was experiencing symptoms similar such as abdominal discomfort, pain, and
frequent, loose stools. If the nurse and I would have tried some relaxation techniques with the
patient, there’s a potential it could have eased his anxiety.
Concept maps can be beneficial in nursing, especially with patient scenarios such as this
one. A concept map can help organize and plan the nursing care that will be provided to the
patients each day. The map will include the priority patient problem, cues, new data, and
assessments related to the priority issue (Schuster, 2020). With the information listed, the nurse
can analyze the map and come up with clinical judgments based on the interpreted data
(Schuster, 2020). My nurse and I tried various techniques with this patient as well as contacted
the physician. If the nurse and I would have put our heads together to create a concept map,
there’s a possibility we could have come up with more interventions for this patient and
implemented a plan.
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References
Cangemi, D. J., & Lacy, B. E. (2019). Management of irritable bowel syndrome with diarrhea: A
review of nonpharmacological and pharmacological interventions. Therapeutic Advances
in Gastroenterology, 12, 175628481987895.
https://doi.org/10.1177/1756284819878950
Schuster, P. M. (2020). ’Twas the Night Before Clinical . In Concept mapping: A clinical
judgement approach to patient care (pp. 1–25). essay, F.A. Davis Company.

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1

CLINICAL EXEMPLAR PAPER

Clinical Exemplar Paper

College of Nursing, University of South Florida

Cognitive behavioral therapy can include techniques such as cognitive restructuring,

patient, there’s a potential it could have eased his anxiety.

review of nonpharmacological and pharmacological interventions. Therapeutic Advances

in Gastroenterology, 12, 175628481987895.

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